Job Description

Job Title:                     

  Credentialing Specialist

Reports To:                 

   Business Office Manager

Job Summary:                  

   To timely and accurately credential all licensed professional medical, dental and behavioral health staff.


Qualifications and Requirements:

To perform this job successfully, and individual must be able to perform each essential job duty satisfactorily.  The requirements listed below are representative of the knowledge, skill, and/or ability required.  This job description in no way implies that these are the only duties to be performed and may be modified, interpreted and/or applied in any way as necessary. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties.


Essential Job Duties:

  • Performs all tasks necessary to credential all licensed provider staff.
  • Performs Primary Source Verification of all staff required to be credentialed.
  • Verifies that all licenses, certifications and credentials are accurate and current.
  • Prepares all necessary paperwork required for providers to practice and to receive payment from insurance, private and government agencies.
  • Obtains signatures from all providers as needed.
  • Ensures that all licenses and credentials do not lapse.
  • Provides sufficient time and notification for providers to renew their licensure and credentialing requirements prior to expiration.
  • Processes and submits required documents.
  • Keeps supervisor informed of any and all challenges to the credentialing process.
  • Communicates with payers, agencies and CCHCI staff.
  • Communicates with insurance companies to ensure all credentialing requirements are being met and are current for all providers.
  • Communicates with private and government agencies to ensure that all requirements are being met and are current for all providers.
  • Communicates with providers and licensed professional staff to ensure that all steps necessary to maintain current licensure and credentialing are being taken.
  • Communicates with Health Center Management to assist them in responding to request for information regarding licensure and credentialing of providers and licensed professional staff.
  • Communicates with supervisor whenever free time is available to assist medical billers.
  • Develops and improves skills
  • Remains current in all changes to credentialing requirements of payers and agencies.
  • Participates actively in routine staff meetings.
  • Participates in training related to documentation, coding and billing compliance and updates to the Practice Management Software in order to be able to assist medical billers.
  • Participates in collaborative meetings/trainings as available and necessary.
  • Improves development through internal and external trainings provided.
  • Seeks opportunities for growth and advancement within the department.


Required Education, Experience, Certificates & Licenses:

  • High School diploma or GED.
  • Any combination of experience and/or education that provides the necessary combination of skills.
  • One year of experience in credentialing.


Required Language Skills:

  • Ability to comprehend and compose effective instructions, correspondence and communications in English in both oral and written format.
  • Bilingual in English and Spanish preferred, but not required.


Physical Requirements:

  • Ability to occasionally exert enough force to move objects weighing up to 10 pounds.
  • Ability to continuously remain in a stationary position.
  • Ability to occasionally move about inside the work place to access files, office machinery, etc.
  • Possesses hand-eye coordination and manual dexterity necessary to constantly operate computer, telephone, and other office machinery.
  • Possesses close visual acuity necessary to accurately record and view information on a computer monitor, handwritten and typed documents.
  • Ability to discern the nature of sounds at a normal spoken volume.


Other Required Knowledge, Skills, and Abilities:

  • Ability to add, subtract, multiply and divide in all measure, using whole numbers, common fractions and decimals.
  • Ability to compute rate, ratio and percent.
  • Ability to gather data in an organized fashion from varied sources.
  • Ability to perform variety of assignments requiring independent judgment.
  • Ability to deal with challenges involving one or more variables in routine situations.
  • Knowledge of billing, medical records, health plans, and community health centers preferred.
  • Knowledge of ICD, CPT, and NDC codes preferred.
  • Computer literacy required.
  • Knowledge of Electronic Health Records preferred.


Work Environment & Conditions:

  • Work environment is usually typical of an administrative office setting with no substantial exposure to adverse environmental conditions.